Immune-mediated Pericarditis With Pericardial Tamponade During Nivolumab Therapy.

A 69-year-old man with metastatic lung adenocarcinoma presented with pericarditis and pericardial tamponade during nivolumab treatment, despite near-complete response on images performed during response evaluation. Further investigation found no evidence of pericardial or pleural cancer involvement, and pathologic evaluation showed immune-related adverse effect. Surgical and steroid treatments were used, with excellent results, and no disease progression on follow-up despite drug discontinuation because of toxicity. Although life-threatening immune-related adverse effects are not frequent when using checkpoint inhibitors, and cardiotoxicity is very rare, different clinical manifestations may occur, and some of them can be fatal in case of inadequate management. It may be challenging to make an etiological diagnosis; however, favorable outcomes can be achieved when prompt directed treatment is promoted.

Primary monophasic synovial sarcoma of the pleura: Neoadjuvant chemotherapy followed by complete resection.

We describe a rare case of primary pleural synovial sarcoma in a 27-year-old man with a 4-month history of dry cough and left-sided chest pain. A CT scan showed a large cystic mass in the left pleural cavity. The patient underwent two video-assisted thoracoscopic biopsies and the diagnosis of synovial sarcoma of the pleura was established. After neoadjuvant chemotherapy, which resulted in a partial response, the tumor was completely resected with extrapleural pneumonectomy. Pathological findings showed less than 5% of viable cancer and free surgical margins. The patient is clinically well 24 months after surgery, with no evidence of recurrent disease.

Evaluation of therapeutic response with 18-FDG PET-CT for non-small cell lung cancer case report and literature review

Positron Emission Tomography / Computed Tomography (PET-CT) is increasingly being used as to complement conventional imaging methods and improve the management of patients with non-small cells lung cancer (NSCLC). The objective of this work is to report on a case in which PET-CT was used as a complementary method to evaluate the therapeutic response in a patient with NSCLC, and to carry out a literature review of the theme. Female patient, 65 years-old, with NSCLC, stage IIIA (T2N2M0), was submitted to exclusive neoadjuvant chemotherapy and presented good response to the treatment, classified by the morphological criteria of the RECIST (Response Evaluation Criteria in Solid Tumors) as a partial response (reduction equal to or greater than 30 percent in the sum of the widest diameter of all the target lesions in the computed tomography). The metabolic evaluation by PET-CT showed a complete response (reduction equal to or higher than 80 percent at maximum SUV of the lesions), which was confirmed in the histopathological analysis of the surgical samples. In the case presented, and through the literature review, we show that the evaluation of response with metabolic criteria, associated with morphological criteria, may be more accurate than the use of morphological criteria alone.

Prolongation of patency of airway bypass stents with use of drug-eluting stents.

OBJECTIVE: Airway bypass by transbronchial fenestration has been shown to improve forced expiratory volume and flow in explanted emphysematous human lungs. We previously demonstrated the feasibility and safety of airway bypass stent placement in a canine model, but we found that most stents occluded within 1 week. The aim of this study was to evaluate the influence of controlled-release paclitaxel-eluting stents on prolongation of patency. METHODS: With the subject dogs under general anesthesia, suitable segmental and subsegmental bronchial wall sites were selected by direct visualization with a flexible bronchoscope. A Doppler probe was used to detect and avoid sites with adjacent blood vessels. Transbronchial passages were formed with a 25-gauge transbronchial needle-tipped catheter and dilated with a 2.5-mm balloon integrated into the needle catheter. A specifically designed expandable stainless steel stent (3 mm long x 3 mm wide) embedded in a sleeve of silicone rubber was placed within the passage and expanded until secured about the bronchial wall. Fifty control stents (no paclitaxel impregnation) and 107 paclitaxel-eluting stents were placed in 25 dogs. Animals underwent bronchoscopy at intervals to assess stent patency. RESULTS: Eight instances of minor and brief bleeding occurred during stent placement; all resolved without incident. There were no pneumothoraces or deaths associated with stent placement. No delayed complications occurred. No identifiable paclitaxel-related toxicity was observed. At 1, 4, 8, and 12 weeks, the patency rates were 10%, 0%, 0%, and 0% for control stents and 100%, 96%, 76%, and 65% for paclitaxel stents. CONCLUSION: In an animal model, the use of specifically designed paclitaxel-eluting airway bypass stents was both feasible and safe. These stents resulted in a significant prolongation of patency.

Bronchial airway anastomotic complications after pediatric lung transplantation: incidence, cause, management, and outcome.

OBJECTIVE: Airway complications are a recognized surgical complication and an important source of morbidity after adult lung transplantation. Little is known about these complications after pediatric lung transplantation. METHODS: Data of pediatric lung transplants performed between January 1990 and December 2002 in a single pediatric institution were reviewed retrospectively. RESULTS: A total of 214 patients, with a mean age of 9.8 +/- 6.1 years (range 0.01-19.7 years), underwent 239 lung transplants: 231 bilateral and 8 single. Mean follow-up was 3.4 years. Forty-two airway complications requiring interventions (stenosis = 36; dehiscence = 4; malacia = 2) developed in 30 recipients (complication rate: 9% of 470 bronchial anastomoses at risk). There were airway complications in 29 bilateral lung transplants (13%) and 1 single lung transplant (13%). Mean time to diagnosis was 51 +/- 27 days (median: 53, range 1-96 days), and diagnoses were made in 90% of patients within the first 3 months after transplantation. Preoperative Pseudomonas cepacia, postoperative fungal lung infection, and days on mechanical ventilator were found to be significant risk factors on multivariate analysis (P = .002, P = .013 and P = .003, respectively). Treatment included rigid bronchoscopic dilatation in 17 patients, balloon dilatation in 13 patients, and stent placement in 12 patients. Other treatments consisted of debridement, fibrin glue application, chest tube placement, and pneumonectomy followed by retransplantation. No patients died as a direct result of airway complications. There was no significant difference in the incidence of bronchiolitis obliterans or overall survival in comparison with patients who did not have airway complications. CONCLUSIONS: Airway complications are a significant cause of morbidity after pediatric lung transplantation. The majority are successfully treated, and patient outcomes are not adversely affected.

Role of open lung biopsy in lung transplant recipients in a single children's hospital: a 13-year experience.

BACKGROUND: There are few data in the literature regarding the utility of open lung biopsy for the assessment of graft dysfunction after pediatric lung transplantation. The aim of this study is to review our experience with diagnostic open lung biopsy in lung transplant recipients in a children's hospital. METHODS: Records of lung transplant recipients from January 1990 through December 2002 were reviewed to identify the indications, outcomes, and complications of open lung biopsy. RESULTS: Two hundred twenty-four patients (mean age, 9.9 +/- 6.2 years; median age, 11 years; age range, 0.01-19.6 years) underwent 249 lung transplantations: 231 bilateral, 8 single, and 10 heart-lung transplantations. Mean follow-up was 3.4 years. One hundred three open lung biopsies were performed in 89 (40% of all recipients) patients. Thirteen recipients underwent open lung biopsy twice, and 1 recipient had 3 open lung biopsies. The indications for open lung biopsy were suspicion of bronchiolitis obliterans (n = 70), posttransplantation lymphoproliferative disorder (n = 15), infection (n = 8), and unexplained respiratory failure (n = 10). A new diagnosis was made in 49 biopsies (48%), 50 biopsies (49%) confirmed the preoperative clinical diagnosis, and 4 biopsies (3%) were nondiagnostic. Bronchiolitis obliterans was confirmed in 40 (57%) of 70 open lung biopsies, posttransplantation lymphoproliferative disorder was confirmed in 4 (27%) of 15 open lung biopsies, and infection was confirmed in 6 (75%) of 8 open lung biopsies. A change in therapy occurred in 69% of the cases as a result of the diagnosis made from open lung biopsy. There was no mortality as a direct result of open lung biopsy. Eleven major complications and 22 minor complications occurred in 103 procedures. CONCLUSION: Open lung biopsy can be performed safely, and established or confirmed a diagnosis in 97% of the cases. A change in therapy occurred in 69% of the cases as a result of the diagnosis made from open lung biopsy. In our experience open lung biopsy appears to be a useful tool.

Feasibility and safety of airway bypass stent placement and influence of topical mitomycin C on stent patency.

OBJECTIVE: Airway bypass via transbronchial fenestration has been shown to improve forced expiratory volume and flow in explanted human emphysematous lungs. The aim of this study was to evaluate the feasibility and safety of in vivo airway bypass stent placement by using a canine model and to assess the influence of topical mitomycin C on the prolongation of stent patency. METHODS: With dogs under general anesthesia, suitable segmental and subsegmental bronchial wall sites were selected by direct visualization with a flexible bronchoscope. Peribronchial blood vessel injury was avoided by using a Doppler probe. Transbronchial fenestration was formed with a 22-gauge transbronchial needle, and the passage was then dilated with a 2.5-mm angioplasty balloon. A balloon expandable stainless-steel stent (3 mm long x 3 mm wide) with a sleeve of silicone rubber covering was placed within the fenestration. Animals were bronchoscoped weekly to assess stent patency. Seventy stents were placed in 12 dogs. Thirty-five served as controls, and the other 35 received transbronchoscopic topical application of mitomycin C once weekly to evaluate the effect on the maintenance of stent patency. Mitomycin C stents were divided into 4 groups according to the number of treatments: group A, 1 treatment only; group B, 4 weeks; group C, 7 weeks; and group D, 9 weeks. Each once-weekly mitomycin C application consisted of 0.2 mL at a concentration of 1 mg/mL, delivered through a small polyethylene catheter. RESULTS: Four instances of minor and brief bleeding occurred during stent placement and resolved without incident. One pneumothorax occurred and was treated by chest tube placement, without any adverse sequelae. There was no mortality associated with stent placement. No delayed hemorrhage or pneumothorax occurred. All control stents were occluded at the 1-week follow-up. The median durations of stent patency for group A (n = 8), group B (n = 9), group C (n = 10), and group D (n = 8) were 3, 8, 13, and greater than 20 weeks, respectively. CONCLUSIONS: Airway bypass stent placement can be performed safely. In an animal model, most stents became occluded within 1 week, but topical mitomycin application resulted in significant prolongation of patency.

Repair of congenital heart lesions combined with lung transplantation for the treatment of severe pulmonary hypertension: a 13-year experience.

OBJECTIVE: In patients with severe pulmonary hypertension associated with congenital heart disease, we prefer to perform repair of the congenital heart disease and lung transplantation whenever feasible so as to augment the donor pool and avoid the cardiac complications associated with heart transplantation. We report our experience with repair of congenital heart disease and lung transplantation and compare the results with those of patients who underwent heart-lung transplantation during the same period. METHODS: The records of patients who had repair of congenital heart disease and lung transplantation (n = 35) and heart-lung transplantation (n = 16) between 1990 and 2003 were reviewed. RESULTS: The underlying congenital heart disease in the repair of congenital heart disease and lung transplantation group included transposition of great vessels (n = 2), atrioventricular canal defect (n = 2), ventricular septal defect (n = 9), pulmonary venous obstruction (n = 7), scimitar syndrome (n = 2), pulmonary arterial atresia or stenosis (n = 5), and others (n = 8). Thirteen of the patients undergoing repair of congenital heart disease and lung transplantation (37.1%) had the congenital heart disease repaired before lung transplantation; the remaining congenital heart disease repairs were performed concurrently with transplantation. Sixteen patients underwent heart-lung transplantation because of poor left ventricular function or single-ventricle anatomy. Freedoms from bronchiolitis obliterans at 1, 3, and 5 years were 72.9%, 54.7%, and 54.7% for the repair of congenital heart disease and lung transplantation group and 77.8%, 51.9%, and 38.9% for the heart-lung transplantation group, respectively. Survivals at 1, 3, and 5 years were 62.9%, 51.4%, and 51.4% for the repair of congenital heart disease and lung transplantation group and 66.5%, 66.5%, and 60% for the heart-lung transplantation group, respectively. CONCLUSION: Repair of congenital heart disease and lung transplantation is a feasible treatment option. Long-term outcome is determined by associated complications related to lung transplantation. Despite the complexity of combined congenital heart disease repair with lung transplantation and the resulting perioperative morbidity, the patients had similar outcomes to those of patients who underwent heart-lung transplantation.

When to remove a chest tube? A randomized study with subsequent prospective consecutive validation.

BACKGROUND: Operative procedures on the pleural space are usually managed by chest tube drainage. Timing for removing the tube is empirically established, with wide variation among surgeons. Our objective was to evaluate the effectiveness and safety of establishing a volume of 200 mL/d of uninfected drainage as a threshold for removal of chest tube, as compared with more frequently used volumes of 100 and 150 mL/d. STUDY DESIGN: A prospective randomized study was performed in a single institution. Patients (n = 139) submitting to pleural drainage after surgical procedures were randomized to one of three groups, defined by the planned timing of chest tube removal (depending on the threshold volume per day of pleural fluid drained): G-100 (< or = 100 mL/d, n = 44); G-150 (< or =150 mL/d, n = 58); and G-200 (< or = 200 mL/d, n = 37). Subsequently, another 91 consecutive patients had chest tubes removed when drainage was less than 200 mL/d (G-val, prospective validation group). All patients had similar discharge and 60-day followup. Drainage time, hospital stay, and reaccumulation rate were registered. RESULTS: Drainage time (median days: 3.5 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) and hospital stay (median days: 4 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) were not statistically different among groups. Radiologic reaccumulation rates were 9.1% for G-100, 13.1% for G-150, 5.4% for G-200, and 10.9% for G-val, and the thoracenteses rates were 2.3%, 0.8%, 2.7%, and 3.3%, respectively, with no major differences among groups (G-100 versus G-150 versus G-200; G-200 versus G-val). CONCLUSIONS: Increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation. This volume (200 mL/d) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks.